Clinico-radiological parameters, biochemical and molecular alterations predicting remission and recurrence after surgical treatment of corticotroph adenomas - Cushing's disease.

OBJECTIVES: Endonasal endoscopic transsphenoidal surgery (TSS) and resection of pituitary adenomas is considered to be the gold standard treatment for Cushing's Disease (CD). Even with various recent advances in management, disease persistence and recurrences are common in these patients. The remission rate in the global population after surgery has been reported to vary widely from 64 to 93%. This study aims to determine various clinical, biochemical, radiological and histological factors that correlate with persistence and recurrence in patients with CD. This study also aims to understand the clinicopathological significance of EGFR-MAPK, NF-kB and SHH pathway activation and to study the protein expression levels of activation markers of these pathways viz. c-Fos , c-Jun, GLI-1 , pMEK, NR4A1 and p44 in functioning corticotroph pituitary adenomas. METHODS: From January 2009 to September 2022, the clinical data of 167 patients who underwent surgical treatment (n=174 surgeries) for Cushing's disease was ambispectively analysed with a median follow up of 8.1 years (1-13.29 years). The preoperative clinical, biochemical, radiological features, operative findings, postoperative clinical and biochemical data, histopathological and molecular profile, were retrieved from electronic records. The patients were followed up to assess the remission status. RESULTS: Among the 174 surgeries performed, 140 were primary surgeries, 22 were revision surgeries, 24 surgeries were for paediatric patients and 12 surgeries were performed in patients with Nelson syndrome. In the primary surgery cohort, 74.3% were females and the average age was 28.73 years (SD 10.15). 75% of the patients experienced remission after primary surgery compared to 47.4% in revision surgery. The remission rate in paediatric patients was 55.5%. Post-operative day 1 plasma cortisol (p<0.001; AUC 0.8894 [0.8087-0.9701]) and ACTH (p<0.001; AUC 0.9 [0.7386-1]) levels were seen to be strong independent predictors of remission in the primary surgery cohort. Remission rates after Endoscopic TSS were more than that after microscopic TSS, in patients undergoing primary surgery (81.08% vs 57.14%; p=0.008). Presence of adenoma on histopathological examination (HPE) was also a strong predictor of disease remission (p=0.020). On categorising based on surgical approach and HPE, microscopically operated patients without histopathological evidence of adenoma had significantly higher odds of non-remission (OR 38.1 95% CI 4.2-348.3) compared to endoscopically operated patients with adenoma on HPE. Lower immune reactivity score (IRS) of NR4A1 was found to correlate with higher remission rates (p=0.074). However, none of the molecular markers studied viz. c-Fos , c-Jun, GLI-1, pMEK and p44 showed a significant correlation with the preoperative cortisol values. CONCLUSION: Remission rate after primary surgery is higher as compared to that after revision surgery, and that in paediatric patients is lower as compared to adults. Post-operative day 1 plasma cortisol and ACTH levels are strong independent predictors of remission in the primary surgery cohort. Endoscopic approach with histopathological evidence of adenoma is associated with a higher remission rate and thus endoscopy should be the approach of choice in these patients with the goal of identification of an adenoma on histopathological analysis.

Re-Admissions of 'Unknown' Traumatic Brain Injury Patients - Inadequacy of Rehabilitative Services in a Developing Country.

BACKGROUND: In neurosurgical practice, continuous care after discharge and the ability to detect subtle indicators of clinical deterioration are mandatory to prevent the progression of a disease. The care of 'unknown' patients discharged to rehabilitation homes may not have this privilege, especially in resource-poor countries such as India. OBJECTIVE: We have attempted to study the causes and outcomes of re-admissions of 'unknown' patients with previous traumatic brain injury (TBI) to estimate the quality of nursing care in our rehabilitation centers. MATERIAL AND METHODS: The electronic hospital records of all consecutive 'unknown' TBI patients with unplanned re-admissions at our institute from January 2014 to December 2018 were retrospectively reviewed and analyzed for the factors determining the risk and outcomes of re-admission. RESULTS: Out of 245 patients sent to rehabilitation homes at discharge, 47 patients (19.18%) were re-admitted. A total of 33 patients (70%) were re-admitted between 1 month and 1 year. Out of these, 38 patients (80.9%) were re-admitted because of preventable causes. Fifteen patients (31.9%) died during the hospital stay. The rest of the 32 (68%) patients were discharged after the management of the concerned condition with an average hospital stay of 9 ± 11.1 days. The average Glasgow coma scale (GCS) at re-admission of the patients who died was 6 (range 3-11). Two patients were brought in the brain dead status, whereas 20 patients (42.6%) had a GCS of 5 or below at the time of re-admission. The risk of mortality among patients with non-preventable causes was 88.9% (8/9) compared to preventable causes 18.4% (7/38). However, preventable causes for re-admission are much more common, resulting in nearly a similar overall contribution to mortality. CONCLUSIONS: There is a high rate of mortality and morbidity in 'unknown' patients with TBI because of poor post-discharge care in developing countries. Because preventable causes are the major contributor to re-admissions, the re-admission rate is a good indicator of a lack of adequate rehabilitative services. The need for improving the post-discharge management of 'unknown' patients with TBI in resource-poor countries cannot be over-emphasized.

Innovations in craniovertebral junction training: harnessing the power of mixed reality and head-mounted displays.

OBJECTIVE: The objective of this study was to analyze the potential and convenience of using mixed reality as a teaching tool for craniovertebral junction (CVJ) anomaly pathoanatomy. METHODS: CT and CT angiography images of 2 patients with CVJ anomalies were used to construct mixed reality models in the HoloMedicine application on the HoloLens 2 headset, resulting in four viewing stations. Twenty-two participants were randomly allocated into two groups, with each participant rotating through all stations for 90 seconds, each in a different order based on their group. At every station, objective questions evaluating the understanding of CVJ pathoanatomy were answered. At the end, subjective opinion on the user experience of mixed reality was provided using a 5-point Likert scale. The objective performance of the two viewing modes was compared, and a correlation between performance and participant experience was sought. Subjective feedback was compiled and correlated with experience. RESULTS: In both groups, there was a significant improvement in median (interquartile range [IQR]) objective performance with mixed reality compared with DICOM: 1) group A: case 1, median 6 (IQR 6-7) versus 5 (IQR 3-6), p = 0.009; case 2, median 6 (IQR 6-7) versus 5 (IQR 3-6), p = 0.02; 2) group B: case 1, median 6 (IQR 5-7) versus 4 (IQR 2-5), p = 0.04; case 2, median 6 (IQR 6-7) versus 5 (IQR 3-7), p = 0.03. There was significantly higher improvement in less experienced participants in both groups for both cases: 1) group A: case 1, r = -0.8665, p = 0.0005; case 2, r = -0.8002, p = 0.03; 2) group B: case 1, r = -0.6977, p = 0.01; case 2, r = -0.7417, p = 0.009. Subjectively, mixed reality was easy to use, with less disorientation due to the visible background, and it was believed to be a useful teaching tool. CONCLUSIONS: Mixed reality is an effective teaching tool for CVJ pathoanatomy, particularly for young neurosurgeons and trainees. The versatility of mixed reality and the intuitiveness of the user experience offer many potential applications, including training, intraoperative guidance, patient counseling, and individualized medicine; consequently, mixed reality has the potential to transform neurosurgery.

SimSpine: A Cost-Effective Spinal Endoscopy Training Prototype for Neurosurgical Residents Skills Training.

OBJECTIVE: To compare the SimSpine (indigenously developed, low-cost model) and EasyGO! (Karl Storz, Tuttlingen, Germany) systems for simulation of endoscopic discectomy. METHODS: Twelve neurosurgery residents, 6 in postgraduate years 1-4 or equivalent (junior) and 6 in postgraduate years 5-6 or equivalent (senior), were randomly allocated (1:1) to either EasyGO! or SimSpine endoscopic visualization systems for endoscopic lumbar discectomy simulation on the same physical simulator. After the first exercise, the participants switched over to the other system, and the exercise was repeated. Time taken to dock the system, time to reach annulus, time required for task completion, dural violation, and volume of disc material removed were used for calculating objective efficiency score. Subjective scoring (Neurosurgery Education and Training School [NETS] criteria) was performed by 4 blinded mentors based on recorded video on 2 separate occasions 2 weeks apart. Cumulative score was calculated based on efficiency and Neurosurgery Education and Training School scores. RESULTS: Performance metrics were similar across the 2 platforms, regardless of participant seniority (P > 0.05). Time to reach disc space and discectomy time improved for both EasyGO! (P = 0.07 and P = 0.03, respectively) and SimSpine (P = 0.01 and P = 0.04, respectively) between first and second exercises. Efficiency and cumulative scores were better (P = 0.04 and P = 0.03 respectively) when EasyGO! was used as the first device compared with SimSpine. CONCLUSIONS: SimSpine is a cost-effective viable alternative to EasyGO for endoscopic lumbar discectomy simulation-based training.

Correlation of Surgical Outcomes of Petroclival Meningiomas with Clinicoradiologic Parameters and Molecular and Chromosomal Alterations.

OBJECTIVE: To identify clinical, radiologic, intraoperative, histopathologic, and molecular factors that might affect the surgical outcome of petroclival meningiomas. METHODS: Medical records of 53 cases of petroclival meningiomas operated from 2003 to 2021 were reviewed for clinicoradiologic and molecular factors that were correlated with extent of resection. RESULTS: Modified Dolenc-Kawase anterior transpetrous rhomboid (44, 83.0%) was the most commonly used approach, followed by retrosigmoid (2, 3.8%) and combined (7, 13.2%) approaches. Hypointense tumors on T2-weighted magnetic resonance imaging (odds ratio [OR] 5.85; 95% confidence interval [CI] 1.70-20.41) and presence of brainstem edema (OR 4.53; 95% CI 1.36-15.12) were found to be significant factors increasing the likelihood of subtotal resection (STR; P = 0.004 and P = 0.011, respectively). In the presence of both tumor T2 hypointensity and brainstem edema, there was a significant increase in the likelihood of STR (P = 0.001; OR 25; 95% CI 3.52-177.48). Of the 16 cases for which molecular analysis was performed, no specimen was found to have pTERT, AKT-1 E17K, and SMO L412F and W535L mutations. All (100%) the patients harboring H3K27me3 loss and/or hemizygous CDKN2A deletion had cavernous sinus extension compared with 62.5% of patients without H3K27me3 loss and 72.7% with hemizygous CDKN2A retention. Similarly, hemizygous CDKN2A deletion and H3K27me3 loss were associated with an increase in the rate of brainstem edema from 27.3% to 60% and 25% to 50%, respectively. CONCLUSIONS: T2 hypointense tumor and brainstem edema on preoperative imaging are significant predictors of STR. H3K27me3 loss and hemizygous CDKN2A deletion may be associated with cavernous sinus extension, suggesting their role in tumor spread.

Role of CDKN2A deletion in grade 2/3 IDH-mutant astrocytomas: need for selective approach in resource-constrained settings.

OBJECTIVE: The authors aimed to assess the frequency of homozygous CDKN2A deletion in isocitrate dehydrogenase (IDH)-mutant diffuse astrocytomas (grade 2/3) and to narrow down the clinicopathological indications in which the CDKN2A fluorescence in situ hybridization (FISH) assay is cost-effective in resource-constrained settings. METHODS: IDH-mutant astrocytomas were analyzed for ATRX, p53, MIB1-LI, and p16 expression using immunohistochemistry. The FISH assay was used to evaluate CDKN2A deletion and 1p/19q codeletion. Survival outcomes were assessed according to the different molecular markers. RESULTS: A total of 150 adult patients with IDH-mutant grade 2 (n = 95) and grade 3 (n = 55) astrocytomas (145 primary and 5 recurrent) were analyzed. Using a cutoff value of 30% for defining significant homozygous CDKN2A deletion, none of the grade 2 and 10.9% (6/55) of grade 3 astrocytomas showed this deletion (4 primary and 2 recurrent grade 3 tumors) and were reclassified as grade 4. This mutation was more frequent in recurrent (40%, 2/5) than primary (2.76%, 4/145) gliomas. Half (3/6, 50%) of the CDKN2A-deleted cases demonstrated poor outcomes; 2 of these cases experienced recurrence at 12 and 36 months after surgery, and 1 died at 5 months. The majority of CDKN2A-deleted cases showed marked cellularity (100%), pleomorphism (100%), brisk mitosis (83.3%), and tumor giant cell formation (83.4%). None of the cases with retained p16 expression harbored this deletion. Both overall survival (p = 0.039) and progression-free survival (p = 0.0045) were found to be worse in cases with p16 loss. Selectively performing CDKN2A FISH only in high-risk cases with histomorphological features of anaplasia, p16 loss, or recurrent tumors achieved a sensitivity and negative predictive value of 100%. This approach would have resulted in saving 41.1% of the original expenditure ($6900 US per 150 samples) and 27.6 person-minutes per sample without compromising the identification of deleted cases. CONCLUSIONS: Homozygous CDKN2A deletion is conspicuously absent in grade 2 and rare in primary grade 3 IDH-mutant astrocytomas. The authors propose that restricting use of the FISH assay to cases showing histomorphological features of anaplasia, p16 loss, or recurrent tumors will help this platform to be utilized in the most cost-effective manner in resource-constrained settings.

Modified Dolenc-Kawase anterior petrous rhomboid approach for petroclival meningioma: surgical nuances and complication avoidance.

Resection of petroclival meningiomas has remained challenging because of the critical neurovascular structures that lie in the vicinity, and thus various surgical corridors have been explored over time to figure out the optimum approach. In this video, the authors have highlighted the operative nuances of the modified Dolenc-Kawase (MDK) anterior petrous rhomboid approach. This approach gives access to the prepontine area, Dorello's canal, anterior petrous apex, and upper two-thirds of the clivus with better angulation and surgical flexibility. It is a versatile approach for petroclival lesions that are not extending laterally and inferiorly to the internal auditory canal. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21256.

A High-Fidelity Agar-Based Phantom for Ultrasonography-Guided Brain Biopsy Simulation: A Novel Training Prototype with Visual Feedback.

OBJECTIVE: A novel agar-based phantom was developed and assessed for ultrasonography (USG)-guided brain biopsy training. The phantom provides visual cues combined with sonologic cues, allowing multimodal training. Impact of multimodal training is evaluated through pretraining and posttraining trials. METHODS: Twenty-five participants were divided based on experience with USG-based procedures into familiar (≥3 procedures performed in the past) (n = 14) and unfamiliar (<3 procedures performed) (n = 11). Agar phantoms with an opaque top and transparent middle layer were constructed in transparent glass bowls, each having 12 embedded targets. Participants underwent 2 supervised trials of USG-guided biopsy with aluminum foil covering the glass bowls, eliminating visual cues. Between 2 trials, participants underwent unsupervised self-training on a phantom without foil cover, providing visual cues. Performance was measured through insonation efficiency (EfI), biopsy efficiency (EfB), efficiency score (Ef), error score (Er), and performance score (PS). Scores were compared between and within the 2 groups before and after training. Impact of the self-training session on subjective comfort levels with the procedure was assessed through feedback forms. RESULTS: Familiars had better pretraining EfB, Ef, Er, and PS (P < 0.001) compared with unfamiliars. After training, both performed similarly on all metrics. After training, familiars improved only in EfI (P = 0.001), with the unfamiliars showing significance in all metrics except EfI. CONCLUSIONS: Simulation and phantom-based models can never supplant training through supervised skill application in vivo but our model supplements training by enabling technical skill acquisition, especially for beginners in USG-guided brain biopsy.

Challenges and prospects of neurosurgical teleconsultations in a developing country: a reality check.

OBJECTIVE: The adoption of telemedicine became a necessity during the COVID-19 pandemic because patients found commuting to be difficult owing to travel restrictions. Initially, audio-based teleconsultations were provided. Later, on the basis of the feedback of patients and caregivers, the authors started to provide video-based teleconsultations via WhatsApp. The authors subsequently surveyed the patients and caregivers to determine their satisfaction levels with telemedicine services. METHODS: An anonymized telephone survey of patients who had participated in teleconsultation was conducted with a structured questionnaire. The responses were analyzed and their correlations with the perceived benefits and limitations of audio and video teleconsultation were determined. RESULTS: Three hundred respondents were included in the first round of surveys, of whom 250 (83.3%) consented to video teleconsultation. Among the respondents who participated in both audio and video teleconsultations (n = 250), paired analysis showed that video teleconsultation was perceived as better in terms of providing easier access to healthcare services (p < 0.001), saving time (p < 0.001), and satisfaction with the way patient needs were conveyed to healthcare providers (p = 0.023), as well as in terms of adequacy of addressing healthcare needs (p < 0.001) and consequently providing a higher rate of overall satisfaction (p < 0.001). For both audio and video teleconsultation, overall patient satisfaction was significantly related to only previous exposure to WhatsApp. However, for video consultation, longer call duration (p = 0.023) was an important independent factor. Video teleconsultation was preferable to face-to-face consultation irrespective of educational status, but higher education was associated with preference for video teleconsultation. CONCLUSIONS: Both audio and video teleconsultation are viable cost-effective surrogates for in-person physical neurosurgical consultation. Although audio teleconsultation is more user-friendly and is not restricted by educational status, video teleconsultation trumps the former owing to a more efficient and satisfactory doctor-to-patient interface.

Interval assessment using task- and procedure-based simulations: an attempt to supplement neurosurgical residency curriculum.

OBJECTIVE: The longer learning curve and smaller margin of error make nontraditional, or "out of operating room" simulation training, essential in neurosurgery. In this study, the authors propose an evaluation system for residents combining both task-based and procedure-based exercises and also present the perception of residents regarding its utility. METHODS: Residents were evaluated using a combination of task-based and virtual reality (VR)-based exercises. The results were analyzed in terms of the seniority of the residents as well as their laboratory credits. Questionnaire-based feedback was sought from the residents regarding the utility of this evaluation system incorporating the VR-based exercises. RESULTS: A total of 35 residents were included in this study and were divided into 3 groups according to seniority. There were 11 residents in groups 1 and 3 and 13 residents in group 2. On the overall assessment of microsuturing skills including both 4-0 and 10-0 microsuturing, the suturing skills of groups 2 and 3 were observed to be better than those of group 1 (p = 0.0014). Additionally, it was found that microsuturing scores improved significantly with the increasing laboratory credits (R2 = 0.72, p < 0.001), and this was found to be the most significant for group 1 residents (R2 = 0.85, p < 0.001). Group 3 residents performed significantly better than the other two groups in both straight (p = 0.02) and diagonal (p = 0.042) ring transfer tasks, but there was no significant difference between group 1 and group 2 residents (p = 0.35). Endoscopic evaluation points were also found to be positively correlated with previous laboratory training (p = 0.002); however, for the individual seniority groups, the correlation failed to reach statistical significance. The 3 seniority groups performed similarly in the cranial and spinal VR modules. Group 3 residents showed significant disagreement with the utility of the VR platform for improving surgical dexterity (p = 0.027) and improving the understanding of surgical procedures (p = 0.034). Similarly, there was greater disagreement for VR-based evaluation to identify target areas of improvement among the senior residents (groups 2 and 3), but it did not reach statistical significance (p = 0.194). CONCLUSIONS: The combination of task- and procedure-based assessment of trainees using physical and VR simulation models can supplement the existing neurosurgery curriculum. The currently available VR-based simulations are useful in the early years of training, but they need significant improvement to offer beneficial learning opportunities to senior trainees.

Transcallosal Suprachoroidal Approach for a Small Third Ventricular Colloid Cyst.

Background and Introduction: The interhemispheric transcallosal approach provides an elegant pathway to access the lesions of the third ventricle. However, every step of this approach is fraught with hazards which must be negotiated delicately. A comprehensive knowledge of surgical anatomy coupled with technical skill is necessary for optimum surgical results. Objective: This video aims to address the surgical nuances of the suprachoroidal transcallosal approach while accessing the lesions around the foramen of Monro in the anterior and middle part of the third ventricle. Surgical Technique: A 16-year-old boy presented with worsening headaches with episodes of speech arrest and blank stare for 6 years, which had become more frequent over the past 4-5 months. Radiology showed a subcentimeteric colloid cyst at the foramen of monro. A transcallosal corridor was used to reach the foramen of monro, and the suprachoroidal access was adopted to uncover the colloid cyst and excise it completely preserving the deep veins. Results: The patient had uneventful recovery and radiology showed complete excision of the cyst. Conclusion: Transcallosal approach, being minimally invasive, exploits the natural extra-axial corridor (interhemispheric) obviating the need for a cortical incision. The suprachoroidal approach mitigates the risks of thalamostriate vein injury, basal ganglia stroke, and hemiparesis.

Anterior Petrous Rhomboid Approach for Petroclival Chondrosarcoma.

Access to the petroclival region has always been challenging owing to the surrounding neurovascular structures. The ideal approach to the region depends not only on the specific tumor characteristics, but also on surgeon preference. In this video article, we have highlighted the use of the modified Dolenc-Kawase approach to expand the standard anterior petrosectomy corridor for challenging tumors that need additional exposure.1-5 A 60-year-old woman presented with facial sensory loss and occasional diplopia. On radiological investigation, a densely calcified petroclival lesion was identified (Video 1). A temporal craniotomy with zygomatic osteotomy was performed followed by deroofing of the superior orbital fissure, saucerization of the foramen spinosum, and coagulation and division of the middle meningeal artery. The temporal dura propria was then dissected off the lateral wall of cavernous sinus using a combination of sharp and blunt dissection to expose the modified Dolenc-Kawase rhomboid. A T-shaped dural incision was made along with tentorial sectioning and division of the superior petrosal sinus. Owing to dense calcification in the tumor, a bone Cavitron ultrasonic aspirator (CUSA; Integra LifeSciences, Princeton, New Jersey, USA) was used for debulking of the tumor. Tumor was removed piecemeal alternately using the bone CUSA and scissors. Tumor was dissected from above and below the trigeminal nerve that forms the center of the corridor followed by dissection off the sixth cranial nerve as it enters the Dorello canal. An endoscope may be used at the end to ensure complete removal of the tumor.

Frailty and Neutrophil Lymphocyte Ratio as Predictors of Mortality in Patients with Catheter-Associated Urinary Tract Infections or Central Line-Associated Bloodstream Infections in the Neurosurgical Intensive Care Unit: Insights from a Retrospective Study in a Developing Country.

OBJECTIVE: We aim to evaluate the role of frailty and inflammatory markers in predicting the short-term outcomes after catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI). METHODS: Data regarding the patients' characteristics, isolates on CAUTI and CLABSI, antibiotic susceptibility, frailty (11-point Modified Frailty Index), and inflammatory markers were retrospectively collected. Their impact on the short-term outcomes was assessed using regression modeling response. RESULTS: One hundred and one patients with CAUTI (n = 71) and CLABSI (n = 30) between January 2018 and December 2019 were included in this study. The pooled incidence rates for CAUTI were 5.50 and for CLABSI 3.58 episodes/1000 catheter-days. We observed 74.7% drug resistance in our CAUTI isolates and 93.3% in CLABSI. In the multivariate analysis, frailty (P = 0.006), neutrophil/lymphocyte ratio (NLR) (P = 0.007) and the presence of sepsis (P = 0.029) were found to be significant predictors of in-hospital mortality in CAUTI. In patients with CLABSI, frailty (P = 0.029) and NLR (P = 0.029) were found significant and along with sepsis (P = 0.069) resulted in a regression model with good accuracy in predicting mortality. The receiver operating characteristic curve showed that 11-point Modified Frailty Index and NLR as well as the regression model significantly predicted mortality with an area under the curve of 86.1%, 81.4%, and 95.4%, respectively, in CAUTI, and 70.9%, 77.8%, and 95.2%, respectively, in CLABSI.

Telementoring Feasibility Using a Novel Low-cost Lazy Glass Microsurgical Simulator: A "Proof of Concept" Experimental Study.

BACKGROUND: In order to mitigate the challenges in microsurgical skill acquisition and training, especially in the COVID-19 era, we devised a novel microsurgical telementoring protocol for imparting microsurgical skill training in a socially distanced setting. We objectively analyzed its feasibility among neurosurgical trainees. METHODS: In a controlled experimental design, 8 residents at different stages of their tenure participated in a lazy glass microsurgical simulator-based telementoring exercise. Microsuturing with 4-0 silk, 10-0 nylon on silastic sheets, and eggshell peeling tasks were performed by the residents prior to and after a telementoring session by a panel of 4 neurosurgical experts. Impact of telementoring was assessed in terms of surgical accuracy, efficiency, and dexterity by providing objective (Performance score [PS]), subjective (Neurosurgery Education and Training School [NETS] score), and cumulative scores (CS). Subgroup analysis was performed to assess the impact at different stages of residency. RESULTS: PS, NETS score, and CS were significantly improved by telementoring sessions for 10-0 nylon micro-suturing (P < 0.001), and egg-hell peeling tasks (P < 0.01). PS and CS improved significantly (P = 0.01) after telementoring sessions for 4-0 silk microsuturing. Both pre- and post-training CS were similar across the 2 subgroups PGY 1-4 and PGY 5-6 (P > 0.05). CONCLUSIONS: Telementoring is a viable alternative for neurosurgical resident training in the COVID-19 era, where reduction in elective surgeries and social distancing norms preclude conventional teaching. Lazy glass microsurgical simulator-based structured telementoring protocol is a cost-effective tool to augment surgical proficiency and finesse, irrespective of stage of residency.

Superficial Temporal Artery to Middle Cerebral Artery Bypass for Moyamoya Disease: Surgical Nuances.

Moyamoya disease is a progressive pathology that generally presents with ischemic complications in the pediatric age group.1 Direct and indirect revascularization procedures have been shown to augment the cerebral blood flow and prevent disease progression. Some studies have reported better angiographic outcomes with direct revascularization, though its translation into clinical benefit is yet to be proven in prospective studies.1-4 In addition, direct revascularization is surgically challenging among the pediatric age group due to smaller vessel caliber. We present a case of a 10-year-old girl who presented with symptoms suggestive of transient cerebral ischemia (Video 1). We use a fine bipolar forceps for dissection of superficial fascia over superficial temporal artery (STA) and needle monopolar for elevating the temporalis muscle. The recipient vessel of the appropriate caliber, matching the donor vessel, is selected. An arteriotomy is made in the recipient vessel, following which end-to-side anastomosis of STA to M4 middle cerebral artery is done using 10-0 monofilament nylon suture at a magnification of 15×. First, the heel and toe stitches are taken, followed by an initial central stitch in the front wall, which decreases the likelihood of a through stitch while taking interrupted sutures in the back wall. Anastomosis is then completed with interrupted stitches in the front wall. The patency of bypass is confirmed using indocyanine green angiography. In this article, we attempt to highlight our surgical technique of low-flow STA to M4-middle cerebral artery bypass with special emphasis on tips and tricks for young neurosurgeons to efficiently perform microvascular anastomosis.

Risk factors for Coronavirus disease-associated mucormycosis.

BACKGROUND: The epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies. METHODS: We performed a case-control study comparing cases diagnosed with CAM and taking controls as recovered COVID 19 patients who did not develop mucormycosis. Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded. Multivariate regression analysis was used to identify independent predictors. RESULTS: A total of 352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean of 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases had conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95% CI 1.1-11), use of systemic steroids (aOR 7.7, 95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs. no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6, 95% CI 1.2-2.2). Zinc therapy was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM. CONCLUSION: Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.

Efficacy of antimicrobial medicated ventricular catheters: a network meta-analysis with trial sequential analysis.

There is paucity of evidence regarding relative performance of antibiotic-medicated (AM), silver-medicated (SM) and non-medicated (NM) ventricular catheters in controlling infection rate. We aim to quantitatively synthesize the current evidence after addition of the three-armed British Antibiotic and Silver Impregnated Catheters for ventriculoperitoneal Shunts (BASICS) trial, understand the need for further evidence using trial sequential analysis (TSA) and incorporate the indirect evidence using network meta-analysis (NMA). Randomized controlled trials (RCTs) comparing AM, SM and NM ventriculoperitoneal shunt (VPS) or external ventricular drain (EVD) were included. Antibiotic-medicated VPS show a significantly lower infection rate as compared to non-medicated VPS (RR 0.44; 95% CI: 0.27-0.73; p = 0.001), however, TSA reveals need for further evidence. SM including both EVD as well as VPS were found to be inferior to AM while no significant difference was found in comparison to the NM catheters. In NMA for VPS, the AM were found to be significantly better than SM (RR 0.41, 95% CI: 0.22-0.75) as well as NM (RR 0.42; 95% CI: 0.25-0.71) with a SUCRA of 99.8% and a mean rank of 1. However, antibiotic medicated shunts did not show a statistically significant association with reoperation rate (RR 0.99; 95% CI:0.81-1.20; p = 0.9) with no further need for evidence as per TSA.

Morphometric Analysis of C2 Pedicle in 247 Patients and Proposal for Trajectory and Size of Pedicle Screw.

BACKGROUND: Screw diameters are currently available based on the literature available for the Western population. No data are available in such a large number of patients for the Indian population. OBJECTIVE: The aim of this study was to define the average pedicle size available and to determine the angulation for placement of screws for C2 pedicle in the Indian population. We also try to determine the pedicle screw diameter which can be used universally in most Indian patients, considering the pedicle dimensions. MATERIAL AND METHODS: Retrospective morphometric analysis of CT scans of 247 patients (152 M, 95 F) was done to calculate the C2 pedicle width (PW), pedicle height (PH), pedicle length (PL), pedicle transverse angle (PTA) and the craniocaudal angulation (CCA) of the C2 pedicle. RESULTS: Mean PW in females was 5.3 mm and in males it was 5.9 mm. This difference was statistically significant. The mean PH in the study population was 8.9 mm, while the mean PL was 29.7 mm. The mean PTA was 40.0 degrees and the CCA was 28.4 degrees. CONCLUSION: This is a morphometric analysis of the C2 pedicle which provides information for the surgeons to determine the safe site of entry and trajectory for the screw implantation. We conclude that a screw diameter of 2.7 mm can be safely implanted in a vast majority of the patient population.